research in the integration of behavioral health for adolescents and young adults in primary care settings a systematic review

Journal of Adolescent Health xxx (2016) 1e9 www.jahonline.org Review article Research in the Integration of Behavioral Health for Adolescents and Young Adults in Primary Care Settings: A Systematic Review Laura P Richardson, M.D., M.P.H a, b, *, Carolyn A McCarty, Ph.D a, b, Ana Radovic, M.D., M.Sc c, d, and Ahna Ballonoff Suleiman, DrPH e a Department of Pediatrics, University of Washington, Seattle, Washington Center for Child Health, Behavior and Development, Seattle Children’s Research Institute, Seattle, Washington c Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania d Children’s Hospital of Pittsburgh of the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania e Institute for Human Development, University of California Berkeley, Berkeley, California b Article history: Received January 19, 2016; Accepted November 17, 2016 Keywords: Mental health; Health services; Adolescents; Young adults; Primary care A B S T R A C T Despite the recognition that behavioral and medical health conditions are frequently intertwined, the existing health care system divides management for these issues into separate settings This separation results in increased barriers to receipt of care and contributes to problems of underdetection, inappropriate diagnosis, and lack of treatment engagement Adolescents and young adults with mental health conditions have some of the lowest rates of treatment for their conditions of all age groups Integration of behavioral health into primary care settings has the potential to address these barriers and improve outcomes for adolescents and young adults In this paper, we review the current research literature for behavioral health integration in the adolescent and young adult population and make recommendations for needed research to move the field forward Ó 2016 Society for Adolescent Health and Medicine Published by Elsevier Inc This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/) In the United States, approximately 20% of adolescents and young adults have a mental health or substance misuse disorder [1e3], and these disorders account for a significant portion of the burden of disability for individuals in this age group [4] These behavioral disorders are associated with other areas of risk including higher rates of suicide [5], injury [6], risky sexual activity and unwanted pregnancy [7,8] and low educational or work achievement [9] Despite the recognition of the significant short- and long-term impacts of behavioral health disorders on Conflicts of Interest: The authors have no conflicts of interest to disclose * Address correspondence to: Laura P Richardson, M.D., M.P.H., Seattle Children’s Adolescent Medicine, M/S CSB-200 PO Box 5371, Seattle, WA 98145 E-mail address: laura.richardson@seattlechildrens.org (L.P Richardson) IMPLICATIONS AND CONTRIBUTION Although behavioral health conditions are common sources of morbidity among adolescents and young adults, research in these populations lags behind research in older age groups This article specifically examines integrated care research in this age group and suggests important directions to move the field forward development and the availability of effective treatments, only about one-third of adolescents with a diagnosable behavioral disorder receive appropriate care [10] Rates of mental health treatment decrease further as adolescents transition into young adulthood [11] Of particular concern, only half of adolescents who meet criteria for “severe” impairment from a mental health disorder report having received care [10] and only 40% of 18e25 year olds with a serious mental illness that impairs functioning report receiving treatment [12] On average, 10 years pass from the initial onset of a mental health disorder and seeking treatment, with younger age at onset associated with longer delays in treatment [13] One approach to reducing delay in treatment and improving treatment delivery is the development of models aimed at 1054-139X/Ó 2016 Society for Adolescent Health and Medicine Published by Elsevier Inc This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/) http://dx.doi.org/10.1016/j.jadohealth.2016.11.013 L.P Richardson et al / Journal of Adolescent Health xxx (2016) 1e9 improving recognition and treatment for behavioral health disorders in primary care settings through the integration of behavioral health services into medical settings [14e16] In the United States, it is estimated that 84% of adolescents have an outpatient visit and 66% have a well checkup annually [17] and 70% of young adults report having a source of primary care [18] Among adolescents who are seen in primary care settings, 14%e 38% have been found to meet criteria for a mental health disorder [19e21] Several studies have also shown high rates of mental health comorbidity among individuals with chronic medical illnesses commonly seen in primary care [22,23], which when present is associated with higher levels of medical symptom burden [24e26], health care costs [24], and worse medical outcomes [27] A recent meta-analysis of integrated behavioral health trials across pediatric age groups found that they had a small-to-moderate effect improving the outcomes of mental health and substance use disorders (d ¼ 042; 95% confidence interval, 29e.55; p < 001) [28] Thus, the integration of care has the potential to improve outcomes for both behavioral and physical health In this article, we aim to specifically review research regarding models of integrated behavioral health in primary care settings among adolescent and young adult populations with the aim of describing needed areas of research Review of the Literature To assess the current state of the literature, we conducted a systematic review of the literature using MEDLINE and PsycINFO to identify research studies examining integrated behavioral health interventions for the treatment of mental health and substance use disorders among adolescent and young adult populations in primary care settings Literature searches contained four categories of search terms, all of which were joined by “and” conditions: (1) Age group designation: “adolescent,” “young adult,” or “college” (2) Variations of integration and/or setting: “primary care,” “school,” “collaborative care,” “integrated care,” or “coordinated care” (3) Variations of “mental health care,” “psychotherapy,” “behavioral health,” or “mental health” (4) Variations of diagnosis: “depression,” “anxiety,” “disruptive behavior,” “eating disorder,” or “substance” To be included, studies had to be focused on older adolescents and/or young adults (study population predominantly within the age range of 13e25 years), examine patient outcomes, have a comparison group, offer an integrated or health care provider-led intervention for a behavioral health condition in primary care, be published in English, and be conducted in 2004 or later Studies of adult populations that did not specifically examine young adults separate from the older adult population were not included For the purposes of this review, we considered schoolbased health clinics and college health clinics to be primary care settings We excluded studies that recruited from the primary care setting but did not have evidence of collaboration or care delivered in that setting, as well as those conducted in the broader school setting such as classroom or campus-wide interventions We only included those focused on treatment or secondary prevention in at-risk individuals As the intent was to look at alcohol and illicit drug misuse, tobacco use interventions were not included In total, when duplicates were excluded, the systematic searches identified 1,086 potential articles of which 1,032 did not meet inclusion criteria based on review of the title or abstract (Figure 1) We conducted full-text article reviews for the remaining 54 articles plus an additional articles identified via bibliographies of identified literature for a total of 57 Of these 57, 36 articles were excluded The reasons for exclusion included the following: pilot or feasibility trial with no comparison group (19 studies), repeat use of a study sample without the presentation of new patient outcomes (8 studies), intervention not in a primary care setting (7 studies), not intervention trial (2), and no behavioral outcomes provided (1) Based on full-text review, 21 trials were identified for inclusion As detailed in Table 1, studies meeting inclusion criteria were conducted in multiple countries including the United States (N ¼ 10), Australia (N ¼ 3), New Zealand (N ¼ 3), South Africa (N ¼ 1), and multiple countries (N ¼ 2, United States and Canada, and United States and Czech Republic) All included studies were reviewed for quality by two independent reviewers using the US Preventive Services Task Force Quality Rating Criteria for Randomized Controlled Trials and Cohort Study Criteria (accessed in Appendix C by Goy et al [29]) Differences in scores were subsequently reconciled via discussion between reviewers To promote accurate comparison, studies identified in our review were organized into three groups with increasing levels of integration Groups were determined a priori based on the framework outlined in the 2010 report on Evolving Models of Behavioral Health Integration in Primary Care: “coordinated care,” “co-located care,” and “integrated care” (briefly described below and as outlined in Table 2) [30,31] In “coordinated care models,” primary care providers work with community-based behavioral health specialists to provide care The behavioral health specialist may serve as an advisor to the primary care provider without seeing the patient or can provide direct care with a coordinated exchange of information Educational interventions that aim to enhance primary care provider skills with support and oversight by mental health providers also fit into this category In “co-located care models,” primary care and behavioral health providers are located in the same setting to simplify the referral process, enhance communication between providers, and remove patient barriers to care “Integrated care” refers to models of care with a shared treatment plan between providers with both behavioral and health elements These models often involve a multidisciplinary team working together using a predefined protocol and a “population-based approach” to tracking outcomes in order to assure improvement for the entire patient panel Our review identified a total of 21 randomized controlled trials with behavioral health outcome measurement among adolescents and young adults: 17 in the category of “coordinated care,” in the category of “co-located care,” and in the category of “integrated care.” Results are discussed by category below, and details of specific studies within each category are provided in Table “Coordinated Care” Research Our review identified 17 studies meeting the criteria for “coordinated care.” Eight studies described interventions in which enhanced behavioral health care was provided by the primary care provider [32e34,40e43,45] One study examined L.P Richardson et al / Journal of Adolescent Health xxx (2016) 1e9 ArƟcles idenƟfied in database search aŌer duplicates removed (n = 1086) ArƟcles Screened (n =1086) AddiƟonal arƟcles idenƟfied via arƟcle bibliographies (n=3) Full Text ArƟcles Reviewed (n =57) ArƟcles excluded at Ɵtle or abstract (n =1,032) ArƟcles excluded at Full Text (n =36) Pilot trial/no comparison: 19 Duplicate study sample: Not primary care: Screening only/not intervenƟon: No paƟent behavioral outcomes: ArƟcles included (n =21) Figure Literature review flowchart provider communication skills training aimed at increasing patient and family engagement in behavioral health care and found improvements in parent-reported child functioning for minority, but not white, youth [32] Five studies examined the effectiveness of provider training in screening, brief motivational interviewing, and referral for substance misuse among adolescent [42,45] and young adult populations [40,41,43] and found the use of these methods to be effective in reducing alcohol or other substance misuse, increasing patient’s readiness to change substance misuse behaviors, and/or decreasing consequences of substance misuse One additional study found that training providers to implement a behavioral health contract paired with consultation among college students reduced the frequency of drinking and driving but not overall substance misuse [33] A final study found that screening coupled with access to a telephone-based parenting intervention was associated with reductions in child aggressive and delinquent behaviors and attention problems [34] Seven studies examined technological approaches to providing behavioral health care in the primary care setting [35e39,44,46e48] Four examined computer-facilitated brief intervention for substance misuse for adolescent and young adults either with [44] or without [37e39] brief advice from the primary care provider and found such strategies to be effective in reducing substance misuse In one of these studies, even a single dose of computer-facilitated motivational interviewing showed sustained effects for a year [39] The remaining three studies used technological interventions to improve outcomes for depression One study examined the use of mobile health symptom-tracking technology for adolescent and young adult depression and found significant improvements in providerreported skills and patient-reported emotional self-awareness but not in mental health outcomes or treatment engagement [46,47] The second study found a cognitive behavioral therapyinformed computer game to have comparable effectiveness to inperson counseling in reducing depressive symptoms among adolescents [48] The third study found that adolescents with depressive symptoms who received motivational interviewing from their providers were more likely to participate in a webbased cognitive behavioral therapy program designed to prevent worsening of symptoms than those who received only brief advice [35,36] Finally, there were two studies employing the integration of self-administered manualized cognitive behavioral therapy into primary care management of bulimia nervosa among predominantly young adult women [49,50] In one study, manualized treatment was associated with significant reductions in bulimic behaviors compared to wait-listed controls [49] The second study did not find any reductions in bulimic behaviors associated with the manualized treatment but did find reductions in bulimic behaviors among individuals in medication treatment arms [50] “Co-located Care” Research Our search did not identify any randomized trials examining outcomes for “co-located care” models We found only two studies that examined behavioral outcomes for youth receiving “co-located care,” both used technological solutions to create virtual co-location and are included here for reference One retrospective study of a convenience sample of youth who had received a telehealth behavioral consultation found improved behavioral outcomes at months postconsultation [55] Additionally, a large cohort study of the provision of telephone access to mental health specialists in primary care found high rates of completion of recommended mental health consultation and reduced symptoms over time for referred youth [56] “Integrated Care” Research We identified four studies meeting the criteria of “integrated care” in the adolescent and young adult age group all of which focused on adolescent depression [51e54] Two studies examined adaptations of adult collaborative care models and involved Table Summary of articles included in literature review (organized by condition treated and level of evidence) Study (country) N Youth age range Intervention target Intervention description Comparison condition Follow-up Main outcomes Quality rating Coordinated care models Wissow et al., 2008 [32] (USA) 418 5e16 years Behavioral and mood problems Primary care provider training in mental health communication skills in order to use skills at child wellness or other visits Usual care months Good Werch et al., 2007 (USA) [33] 155 College students (mean age 19 years) Health behaviors and beliefs Three comparison conditions: Behavioral contract with calendar log Single consultation Both Comparison between three arms, no no-treatment cohort month Borowsky et al., 2004 (USA) [34] 224 7e15 years Violence Screening with physician feedback Optional telephonebased parenting program delivered by parent-educator Usual care months Walton et al., 2013 (USA) [37] 328 12e18 years Cannabis use Computerized brief intervention based on motivational interviewing with or without therapist facilitation Usual care plus informational brochure and Web sites 3, 6, and 12 months Kypri et al., 2004 (New Zealand) [38] 104 17e26 years Alcohol use Web-based assessment and personalized feedback on alcohol use Information pamphlet weeks and months Kypri et al., 2008 (New Zealand) [39] 576 17e29 years Alcohol use Web-based motivational intervention in: A single dose Three doses over months Information pamphlet and 12 months Mertens et al., 2014 (South Africa) [40] 403 18e24 years Substance use Single session brief motivational interviewing with a nurse practitioner plus referral resources Usual care plus list of referral resources months Fleming et al., 2010 (USA and Canada) [41] 986 College students 18 years Substance use Brief motivational interviewingdtwo 15-minute sessions with a physician and two follow-up calls Booklet on general health issues 12 months Intervention associated with greater reductions in impairment among minority but not white youth No changes noted in youth symptoms, but intervention was associated with a decrease in parent symptoms Groups receiving consultation reported increased rates of physical activity, nutrition, and sleep as well as reductions in drinking and driving behaviors Intervention associated with reductions in aggressive and delinquent behaviors and attention problems Parents also reported less child bullying and physical fighting Intervention associated with reduced cannabis-related problems and reduced other drug use (3 and months) but not with reductions in cannabis or alcohol use Intervention associated with reduced total alcohol consumption at weeks but not months, as well as reduced personal problems and academic problems (6 months only) Single dose intervention associated with reduced total alcohol consumption and academic problems Similar results for three-dose intervention Intervention youth had significant reductions in alcohol use scores but not at-risk use of alcohol or marijuana Intervention associated with reduced 28-day alcohol use and alcohol problem index No reduction in binge drinking, health care utilization, injuries, drunk driving, depression, or tobacco use Fair Good Good Good Good Good L.P Richardson et al / Journal of Adolescent Health xxx (2016) 1e9 Good Table Continued Study (country) N Youth age range Intervention target Intervention description Comparison condition Follow-up Main outcomes Quality rating Single 20-minute session including brief motivational interviewing and social network counseling Brief motivational interviewingdtwoethree 1-hour sessions No treatment month Good One-time assessment with feedback session months Intervention associated with reduced use of substances prior to sex and reported trouble due to alcohol use Intervention associated with significantly reduced alcohol use, cannabis use, and psychological distress Computer-facilitated screening and feedback for youth, plus provider led brief advice based on results Usual care (asynchronous) 12 months Mason et al., 2011 (USA) [42] 28 14e18 years, all female Substance use Hides et al., 2013 (Australia) [43] 61 16e25 years Substance use in youth receiving care for anxiety or depression Substance use 2106 (USA) 589 (CZ) 12e18 years D’Amico et al., 2008 (USA) [45] 42 12e18 years Reduction in substance use among high risk youth Brief motivational interviewing intervention during a primary care visit, with telephone follow-up Usual care months Reid et al., 2011 (Australia) [46] Reid et al., 2013 (Australia) [47] 118 14e24 years Depression Use of a phone app to collect data on mood, stress, coping, activities, eating, sleeping, exercise, and substance use for physician review during follow-up Attention control weeks and months Merry et al., 2012 (New Zealand) [48] 187 12e19 years Depression Internet-based cognitive behavioral therapy intervention designed as a fantasy game and months 84 14e21 years Secondary depression prevention among adolescents with subthreshold symptoms Brief motivational interviewing with provider followed by participation in an Internet preventive intervention (14 modules) Usual care (89% received treatment with psychotherapy or medications) Brief advice (2e3 minutes) ỵ Internet preventive intervention (14 modules) Van Vorhees et al., 2008 (USA) [35] Van Vorhees et al., 2009 (USA) [36] 4e8, 12 weeks Intervention associated with significantly reduced alcohol use (US sample only) and marijuana use (Czech sample only) Intervention associated with significant reductions in marijuana use and nonsignificant reductions in alcohol use Intervention associated with increased provider understanding of mental health and patient emotional self-awareness and decreased overall mental health symptoms No significant reductions in depressive or other mental health disorders Intervention associated with reductions in depressive symptoms similar to usual care group and higher rates of depression remission Both groups experienced declines in depressive symptoms, increases in social support by peers, and reductions in depression-related impairment at school The motivational interviewing group was significantly less likely to experience a depressive episode or report hopelessness by 12 weeks Fair Poor Fair Good Fair L.P Richardson et al / Journal of Adolescent Health xxx (2016) 1e9 Harris et al., 2012 (USA and Czech Republic) [44] Fair (continued on next page) Study (country) Table Continued N Youth age range Intervention target Intervention description Comparison condition Follow-up Main outcomes Quality rating 109 18 years and older (mean age 29.5 yrs) Bulimia nervosa Modified cognitive behavioral therapy self-help manual guided by brief sessions with a specialist or nonspecialist health professional Delayed treatment control months Fair 91 18e60 years (mean age 30.6 years) Bulimia nervosa Fluoxetine alone, Fluoxetine plus guided cognitive behavioral therapy self-help book, or placebo plus guided cognitive behavioral therapy self-help book Placebo alone 3e4 months Intervention associated with significant improvements in psychological and bulimic symptom scales, reduced frequency of mean binge eating episodes, and greater remission of eating disordered behaviors Participants receiving fluoxetine had reduced binge eating and vomiting episodes and a greater improvement in psychological symptoms There was no benefit noted from self-help book High rate of treatment drop out in both arms 418 13e21 years Depression Enhanced usual care months Richardson et al., 2014 (USA) [52] 101 13e17 years Depression Enhanced usual care and 12 months Clarke et al., 2005 (USA) [53] 152 12e18 years Depression Medications alone 12 weeks Intervention associated with nonsignificant reduction in depressive symptoms Good 63 12e18 years Depression Quality improvement intervention including depression care management, patient and provider choice of meds, cognitive behavioral therapy, or both Collaborative care intervention delivered by depression care management, patient and family choice of meds, cognitive behavioral therapy or both; stepped care algorithms and psychiatric supervision Cognitive behavioral therapy intervention provided by therapist in conjunction with primary provider-prescribed antidepressant Interpersonal psychotherapy intervention provided by a therapist in school-based health clinic Treatment as usual 12 weeks Intervention associated with reduction in depressive symptoms compared to treatment as usual Good Banasiak et al., 2005 (Australia) [49] Walsh et al., 2004 (USA) [50] Mufson et al., 2004 [54] Intervention associated with significantly improved receipt of treatment, depressive symptoms, mental healthe related quality of life, and satisfaction with care Intervention associated with significantly improved receipt of treatment, depressive symptoms, and functional status as well as higher rates of depression remission Good Good L.P Richardson et al / Journal of Adolescent Health xxx (2016) 1e9 Integrated care models Asarnow et al., 2005 (USA) [51] Poor L.P Richardson et al / Journal of Adolescent Health xxx (2016) 1e9 Table Collaborative care categorization overview Coordinated Co-located Integrated  Routine behavioral health screening in primary care setting  Referral relationships developed between primary care and behavioral health  Methods established for routine exchange of information between treatment settings  Primary care provider may deliver brief behavioral health interventions depending on severity  Medical and behavioral health services located in the same setting  Referral process developed to delineate cases to be seen by behavioral health  Proximity promotes enhanced informal communication and bidirectional consultation  Needs of the clinic population may influence the type of behavioral health services offered  Medical and behavioral services can be located in the either the same or separate facilities  Shared treatment plan between providers with both behavioral and medical elements  Multidisciplinary team works together to deliver care using a prearranged protocol  Use of a database to track the care of patients who screen positive  Protocols and improvement goals target the whole population in the database Adapted from articles by Blount A [31] and Collins et al [30] depression care managers in primary care practices who helped primary care providers with depression assessment, symptom tracking, evidence-based treatment delivery, and advancement of treatment based on prespecified algorithms and with input from psychiatric consultants Both found that the collaborative care was associated with increased treatment engagement and significantly improved outcomes for depression among adolescents compared to usual care [51,52] A third study examined the addition of a brief psychotherapy protocol for antidepressanttreated adolescents in primary care and found that psychotherapy was associated with only mild nonsignificant reductions in depressive symptoms [53] The authors noted that youth in the intervention arm were more likely to choose to prematurely discontinue antidepressants than those receiving usual care and hypothesized that this discontinuation may have attenuated the effects of the intervention The final study examined the integration of interpersonal therapy delivered by trained therapists for teens with depression seen in the school-based health clinic setting They found benefit of interpersonal psychotherapy over treatment as usual particularly in youth with high levels of conflict with mothers and social dysfunction with friends [54] Discussion and Recommendations While behavioral health disorders have a significant impact on the functioning and impairment of adolescents and young adults, our literature review revealed a relatively small number of research studies testing behavioral health integration in this population This limited body of literature is particularly surprising in light of the extensive array of collaborative care studies addressing these conditions in adult populations [57e59] and points to the need for further development and testing of interventions among the adolescent and young adult populations Our review also identified several gaps in the literature in which research would be beneficial in moving the field forward First, more high-quality research is needed in the implementation of integrated care models for the behavioral health conditions that most commonly occur among adolescents and young adults A recent Cochrane review identified 79 randomized controlled trials of integrated care models for depression and anxiety among adult populations with overwhelming evidence for effectiveness in reducing depression and anxiety symptoms [58] In contrast, our search revealed only three randomized controlled trial studies of integrated care models among adolescents, all of which focused on depression We did not identify any randomized controlled trials addressing behavioral health integration for anxiety, the most prevalent disorder during adolescence, nor eating disorders among adolescents which are often medically managed in primary care Similarly, although integrated care models have been tested among younger children with attention deficit disorder [60e63], studies have not included adolescents above age 13 years or young adults Additional opportunities for new research areas include the following: examining effectiveness of brief interventions developed for primary care administration in adult settings among adolescent and young adult populations, evaluation of technological strategies to increase access to psychotherapy in primary care, and improved models for the primary care integration of web-based psychotherapy methods that have been shown to be effective for depression and anxiety in adolescent and young adult populations [64] Our review also suggested the need for more research addressing how developmental stage affects the types of needed supports and interventions Prior research suggests that developmental factors can influence the presentation of mental health symptoms, the ability to be independent in care, the impact of stigma, and the efficacy of particular types of interventions [65e67] For younger teens, parents are often the ones initiating care which may influence interest and engagement in treatment interventions [68e70] The studies in our review differed in the range of included ages, and none were designed with adequate numbers to explore if the intervention was similarly effective across developmental stage Future studies should address this gap and examine if there are consistent patterns to the types of components (e.g., parental engagement, behavioral skills) required at different ages One notable area of absence of developmental information was in the young adult population While most adult studies include individuals who are 18 years and older, our search identified relatively few studies in which integrated behavioral health care was specifically examined in young adults, most of which were focused on substance use in college health settings [35,38e41,46,49,50] However, compared to older adults, young adults have little experience in navigating the system to reach care [18] More research is needed to determine if existing adult collaborative care models are reaching and meeting the needs of this population Additionally, more research is needed to identify key strategies to facilitate the dissemination of behavioral health integration models that have been found to be effective in randomized trials into actual primary care practice in the United States There is good evidence for the effectiveness of integrated care for depression [51e54] and brief motivational interviewing for substance misuse [38,39,42,71] (especially when combined with L.P Richardson et al / Journal of Adolescent Health xxx (2016) 1e9 what is known in the adult literature), but significant work still exists in adopting these programs into practice under the current funding system While our review did identify descriptive papers of large-scale implementation projects [55,56], they did not include rigorous patient-level outcome assessments or comparison groups In the US health care system, the funding of activities related to care management and psychiatric supervision has been a particular challenge that will require creative solutions and might benefit from more research In a recent survey, clinicians identified lack of resources as a key barrier to implementing integrated care plans in Medical Homes [72] Finally, integrated care practice requires specific skills among providers including shared management plans, group case supervision by psychiatrists, and training for depression care managers Further investigation is needed on how to train providers for these skills possibly taking an earlier approach to multidisciplinary training between behavioral health and medical trainees The field of adolescent and young adult health care is rapidly shifting in ways that may create new opportunities for improving behavioral health outcomes for this population The Affordable Care Act opens new opportunities to serve young adults through expansion of health insurance coverage [73,74] The PatientCentered Medical Home model aims to reduce the cost of health care and improve patient experience and population health through the integration of needed services, such as behavioral health, into a single setting [15] School-based health clinics and college health clinics may provide new opportunities to test models that integrate educational and other social supports [75] By expanding our research in integrated care among adolescents and young adults, we will be positioned well to maximize these new opportunities and to improve key behavioral health outcomes Acknowledgments The authors would like to acknowledge Peter Scal MD, MPH, for his contribution to the conceptualization of this paper, Garret Zieve for his assistance in critical review of the literature, and Elizabeth Ozer, PhD, and Robin Harwood, PhD, for providing input on the overall content of the paper and critically reviewing the final manuscript This project is/was supported by the Health Resources and Services Administration (HRSA) of the U.S Department of Health and Human Services (HHS) under grant number UA6MC27378 for $960,000 This information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the US Government References [1] Merikangas KR, He JP, Burstein M, et al Lifetime prevalence of mental disorders in U.S adolescents: Results from the National Comorbidity Survey ReplicationeAdolescent Supplement (NCS-A) J Am Acad Child Adolesc Psychiatry 2010;49:980e9 [2] Kessler RC, Avenevoli S, Costello EJ, et al Prevalence, persistence, and sociodemographic 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(briefly described below and as outlined in Table 2) [30,31] In “coordinated care models,”... developed for primary care administration in adult settings among adolescent and young adult populations, evaluation of technological strategies to increase access to psychotherapy in primary care, and. .. conducted a systematic review of the literature using MEDLINE and PsycINFO to identify research studies examining integrated behavioral health interventions for the treatment of mental health and substance